Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments.     

Prevalence and Comorbidity of Prolonged Grief Disorder in a Sample of Caregivers of Patients in a Vegetative State

Previous studies have shown that Prolonged Grief Disorder (PGD), Post-traumatic Stress Disorder (PTSD) and major depression are autonomous nosological entities. The present study aims at further analyzing the relationship among them in a sample of caregivers of patients in Vegetative State (VS) or Minimally Conscious State (MCS). We also investigated factors predicting the development of PGD. We sampled 40 Caregivers of patients in VS or MCS consecutively admitted to long-term care units. Caregivers were administered the PG-12, the Depression Questionnaire, the SCID I and the Davidson Trauma Scale. Six participants (15%) fulfilled the criteria for PGD, 25% (N = 10) for depression and 25% (N = 10) for PTSD. Although significant correlations emerged among symptom domains of the three disorders, no relevant association was found between a diagnosis of PGD, depression and PTSD. The severity of PTSD symptoms was found to be predictive of PGD. Clinical implications are discussed.     

Perspectives and Experience of Healthcare Professionals on Diagnosis, Prognosis, and End-of-Life Decision Making in Patients with Disorders of Consciousness

In the care of patients with disorders of consciousness (DOC), some ethical difficulties stem from the challenges of accurate diagnosis and the uncertainty of prognosis. Current neuroimaging research on these disorders could eventually improve the accuracy of diagnoses and prognoses and therefore change the context of end-of-life decision making. However, the perspective of healthcare professionals on these disorders remains poorly understood and may constitute an obstacle to the integration of research. We conducted a qualitative study involving healthcare professionals from an acute care university medical center. A short questionnaire captured demographic data as well as the experience of participants with DOC patients. A semi-structured interview was used to explore attitudes toward ethical issues identified in a previous literature review. Qualitative content analysis of interviews was conducted with the NVivo software. Accurate diagnosis among DOC is often regarded as a challenge, but this was generally not the case for our participants because most reported high confidence in DOC diagnoses. However, participants reported struggling with prognosis, especially because of its essential role for end-of-life decision making and communication with families. Variability of opinion between healthcare professionals was reported and identified by some as a minor issue while others stressed how families struggle with different medical opinions. End-of-life decision making encompassed a large proportion of ethical challenges in these patients, and the removal of artificial nutrition and hydration created significant discomfort in a minority of participants. The concept of futility was subject to wide-ranging understandings with both favorable and unfavorable opinions. Our data suggest that to ensure the incorporation of new evidence-based advances, attention should be directed to the real-world practices and challenges of accurate diagnosis and prognosis. Given pervasive challenges in end-of-life care, we recommend improved training of healthcare professionals in the care of patients with DOC, particularly in end-of life care, understanding the context of decision making, and determining how to optimally integrate new neuroscience research on the care of patients with DOC.     

Nivel de conocimiento de aspectos legales de la enfermedad de Alzheimer en cuidadores,estudiantes y profesionales sanitarios

IntroductionModification of legal capacity is a protective measure involving a judicial procedure; a deeper understanding of this concept is necessary for its execution in such vulnerable populations as patients with Alzheimer disease (AD). Unawareness of a patient's legal capacity and failure to adequately protect them may give rise to situations of avoidable risk.Patients and methodsWe designed a closed survey for informal caregivers of patients with AD, the general population, medical students, and healthcare professionals to determine the degree of understanding of the concept of modified legal capacity.ResultsThe survey was administered to a total of 401 individuals: 100 caregivers, 117 members of the general population, 128 medical students, and 58 healthcare professionals. Women accounted for 66.1% of the sample (n = 265); mean age (SD) was 43.2 (0.9) years. The overall mean survey score was 7.7 (0.9). By group, caregivers scored 7.5 (0.18), the general population scored 6.9 (0.16), students scored 8.4 (0.17), and healthcare professionals scored 8.7 (0.20) (P = .000). Of all respondents, 78.8% had not received information on legal issues related to dementia. Among students, no significant differences in survey score were observed between members of different years (P > .05).ConclusionsThere is a low level of understanding of modified legal capacity and of the legislation governing issues related to cognitive impairment among caregivers, the general population, and even medical students. It is important to design strategies to improve understanding of the concept, particularly among future healthcare professionals.     

Analysis of Wessex Head Injury Matrix (WHIM) scores in consecutive vegetative and minimally conscious state patients

Consensus guidelines defining minimally conscious state (MCS) have been available for some years. However, to date, few measures have been developed that are particularly suited to monitoring MCS patients and there are limited clinical outcome data. The objective of the study was to determine the value of serial repeated assessments using the Wessex Head Injury Matrix (WHIM) to identify changes in vegetative state (VS) and MCS patients. Twenty consecutive VS/MCS patients admitted to a post-acute regional neurorehabilitation unit were assessed using WHIM. Significant differences in both total number of behaviours observed (p < .001) and highest rank behaviour were observed (p = .001) between initial and final WHIM assessments. Preliminary findings suggest that the WHIM is a sensitive measure of subtle changes in VS and MCS patients.     

Prevalence and correlates of burnout in health professionals in Ecuador

BackgroundAlthough burnout is a widespread phenomenon among healthcare professionals, there are no studies about its prevalence in Ecuador. This study assesses the prevalence of burnout syndrome among Ecuadorian healthcare professionals and examine the relationship with their personal and organizational characteristics.MethodsA total of 2404 healthcare professionals (average age 40.0 years; 68.4% women) from the capitals of all 24 provinces in Ecuador participated in this study. Trained psychologists assessed the presence of burnout by applying the Maslach Burnout Inventory. Sociodemographic variables, emotional distress, social support and coping styles as well as organizational variables were also collected.ResultsOf all healthcare professionals surveyed, 2.6% presented burnout syndrome. By dimensions, 17.2% of the participants presented a high level of emotional exhaustion, 13.5% of depersonalization, and 18.2% had reduced personal accomplishment. Being non-mestizo, being classified as a probable case of mental disorder and using more passive coping were associated with a greater probability of presenting burnout; having > 10 years of experience was associated with a lower probability of burnout.ConclusionsA significant number of active health professionals suffer from burnout. It is necessary to develop effective psychotherapeutic interventions for those who have the syndrome and to evaluate potential prevention strategies in those who have not yet developed it.     

Quantitative rates of brain glucose metabolism distinguish minimally conscious from vegetative state patients

The differentiation of the vegetative or unresponsive wakefulness syndrome (VS/UWS) from the minimally conscious state (MCS) is an important clinical issue. The cerebral metabolic rate of glucose (CMRglc) declines when consciousness is lost, and may reveal the residual cognitive function of these patients. However, no quantitative comparisons of cerebral glucose metabolism in VS/UWS and MCS have yet been reported. We calculated the regional and whole-brain CMRglc of 41 patients in the states of VS/UWS (n=14), MCS (n=21) or emergence from MCS (EMCS, n=6), and healthy volunteers (n=29). Global cortical CMRglc in VS/UWS and MCS averaged 42% and 55% of normal, respectively. Differences between VS/UWS and MCS were most pronounced in the frontoparietal cortex, at 42% and 60% of normal. In brainstem and thalamus, metabolism declined equally in the two conditions. In EMCS, metabolic rates were indistinguishable from those of MCS. Ordinal logistic regression predicted that patients are likely to emerge into MCS at CMRglc above 45% of normal. Receiver-operating characteristics showed that patients in MCS and VS/UWS can be differentiated with 82% accuracy, based on cortical metabolism. Together these results reveal a significant correlation between whole-brain energy metabolism and level of consciousness, suggesting that quantitative values of CMRglc reveal consciousness in severely brain-injured patients.     

Mirroring of a simple motor behavior in Disorders of Consciousness

ObjectiveIn patients suffering from Disorders of Consciousness (DOC) electrophysiological recordings at bedside could serve as a complimentary and economical tool to improve diagnosis. We utilized a motor observation and imagination paradigm to gain new insights on preserved cognitive processing in DOC.MethodsEEG brain oscillations were analyzed in 10 VS/UWS (Vegetative State/Unresponsive Wakefulness Syndrome) patients and 7 MCS (Minimally Conscious State) patients and 21 controls during observation and imagination of a grasping movement and group statistics were conducted.ResultsWhile control subjects showed a typical desynchronization at 8–15 Hz during observation of a movement, MCS patients presented an analogue response at 8–10 Hz, but exhibited a synchronization at 12–15 Hz. The VS group did not show a systematic response. Imagery-related activation was only sustained for 1500 ms even in control subjects, therefore, limiting conclusions regarding the ability to follow an instruction. Furthermore, a clinically diagnosed VS patient exhibited EEG responses indicative for MCS.ConclusionResults indicate that MCS patients are still able to process an observed motor behavior on a basic sensory and perhaps even pre-motoric level, but seem not to be capable of “mirroring” the movement like healthy participants.Significance“Real-world” tasks as presented here carry the potential to identify residual cognitive functioning in DOC patients and may ultimately help to lower misdiagnosis rates.     

Etiological explanation, treatability and preventability of childhood autism: a survey of Nigerian healthcare workers' opinion

Background  

Because of their peculiar sociocultural background, healthcare workers in sub-Saharan African subcultures may have various conceptions on different aspects of autism spectrum disorders (ASD), such as etiology, treatment and issues of prognosis. These various conceptions, if different from current knowledge in literature about ASD, may negatively influence help-seeking behavior of parents of children with ASD who seek advice and information from the healthcare workers. This study assessed the opinions of healthcare workers in Nigeria on aspects of etiology, treatability and preventability of childhood autism, and relates their opinions to the sociodemographic variables.     

Connectivity biomarkers can differentiate patients with different levels of consciousness

ObjectiveIn the present study, we searched for resting-EEG biomarkers that distinguish different levels of consciousness on a single subject level with an accuracy that is significantly above chance.MethodsWe assessed 44 biomarkers extracted from the resting EEG with respect to their discriminative value between groups of minimally conscious (MCS, N = 22) patients, vegetative state patients (VS, N = 27), and – for a proof of concept – healthy participants (N = 23). We applied classification with support vector machines.ResultsPartial coherence, directed transfer function, and generalized partial directed coherence yielded accuracies that were significantly above chance for the group distinction of MCS vs. VS (.88, .80, and .78, respectively), as well as healthy participants vs. MCS (.96, .87, and .93, respectively) and VS (.98, .84, and .96, respectively) patients.ConclusionsThe concept of connectivity is crucial for determining the level of consciousness, supporting the view that assessing brain networks in the resting state is the golden way to examine brain functions such as consciousness.SignificanceThe present results directly show that it is possible to distinguish patients with different levels of consciousness on the basis of resting-state EEG.     

Neuromuscular involvement in vegetative and minimally conscious states following acute brain injury

The aim of this study was to evaluate the presence of neuromuscular involvement in patients in vegetative and minimally conscious states (VS, MCS) following acute brain injury. Twenty-two patients (11 in VS, 11 in MCS) admitted to a rehabilitation department underwent nerve conduction, electromyography (EMG) for spontaneous activity and direct muscle stimulation (DMS). Twenty (90.9%) showed abnormal nerve conduction studies, 19 (86.4%) had spontaneous EMG activity, and 7 (31.8%) had abnormal DMS. The time spent in the intensive care unit correlated significantly with the amplitude of the compound muscle action potential of the ulnar nerve and with the amplitude of the sensory nerve action potential of the sural nerve (p < 0.05). No significant differences were found between patients in VS and MCS. Neurophysiological data indicative of neuromuscular involvement are common in patients in VS and MCS. This study underlines the need to implement strategies to prevent and to treat neuromuscular complications in patients in VS and MCS.     

Limited concordance between teachers,parents and healthcare professionals on the presence of chronic diseases in ID-adolescents

Evidence on teachers’ knowledge about somatic and mental chronic diseases among ID-adolescent compared to the knowledge parents and healthcare professionals have, is limited. The aim of this study is: (1) to assess the knowledge of teachers on the presence of chronic diseases in ID-adolescents; (2) to compare teachers with parents and healthcare professionals and parents with healthcare professionals regarding the knowledge on the presence of chronic diseases in ID-adolescents. We obtained data on 1044 ID-adolescents attending secondary schools, fully covering one region of the Netherlands. Teachers, parents and general practitioners (GPs) of the adolescents completed a questionnaire about the occurrence of chronic diseases in their child during the previous 12 months. The questionnaire was derived from the Dutch National Permanent Survey on Living Conditions questionnaire periodically administered in a representative population sample (n ≈ 10,000). Concordance between teachers, parents and healthcare professionals on the presence of chronic diseases in ID-adolescents was relatively low. In about half of all 66 dyads the concordance was for the most part fair and just in 10 dyads good to very good; nine of these latter cases concerned somatic chronic diseases. In addition, teachers reported mostly lower prevalence rates of chronic diseases in ID-adolescents compared to the parents, in particular on mental chronic diseases. Although prevalence rates of chronic diseases among ID-adolescents are very high, knowledge on this among teachers is limited. While information on chronic diseases in ID-adolescents is available among different informants, the disagreement between them reflects different points of view between the informants and probably indicates a lack of communication. The communication among teachers, parents and GPs should be improved to combine the knowledge and information on the presence of chronic diseases in ID-adolescents. This may provide opportunities to improve the support of these adolescents in their school career and in their transition from school to work.     

Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome: a survey of German neurologists

Diagnosis and decisions on life-sustaining treatment (LST) in disorders of consciousness, such as the vegetative state (VS) and the minimally conscious state (MCS), are challenging for neurologists. The locked-in syndrome (LiS) is sometimes confounded with these disorders by less experienced physicians. We aimed to investigate (1) the application of diagnostic knowledge, (2) attitudes concerning limitations of LST, and (3) further challenging aspects in the care of patients. A vignette-based online survey with a randomized presentation of a VS, MCS, or LiS case scenario was conducted among members of the German Society for Neurology. A sample of 503 neurologists participated (response rate 16.4%). An accurate diagnosis was given by 86% of the participants. The LiS case was diagnosed more accurately (94%) than the VS case (79%) and the MCS case (87%, p?相似文献   

Global functional connectivity reveals highly significant differences between the vegetative and the minimally conscious state

A major challenge in the diagnosis of disorders of consciousness is the differential diagnosis between the vegetative state (VS) and the minimally conscious state (MCS). Clinically, VS is defined by complete unawareness, whereas MCS is defined by the presence of inconsistent but clearly discernible behavioural signs of consciousness. In healthy individuals, pain cries have been reported to elicit functional activation within the pain matrix of the brain, which may be interpreted as empathic reaction. In this study, pain cries were presented to six VS patients, six MCS patients, and 17 age-matched healthy controls. Conventional task-related functional magnetic resonance imaging (fMRI) showed no significant differences in functional activation between the VS and MCS groups. In contrast to this negative finding, the application of a novel data-driven technique for the analysis of the brain’s global functional connectivity yielded a positive result. The weighted global connectivity (WGC) was significantly greater in the MCS group compared to the VS group (p < 0.05, family-wise error corrected). Using areas of significant WGC differences as ‘seed regions’ in a secondary connectivity analysis revealed extended functional networks in both MCS and healthy groups, whereas no such long-range functional connections were observed in the VS group. These results demonstrate the potential of functional connectivity MRI (fcMRI) as a clinical tool for differential diagnosis in disorders of consciousness.     

Relationship between Obsessive-Compulsive Symptoms and Anxiety Levels during the COVID-19 Pandemic in Healthcare Professionals <i>vs.</i> Non-Healthcare Professionals

The present study investigated the effect of the COVID-19 pandemic on anxiety levels, contamination and responsibility/control obsessions and associated OC behaviors in healthcare versus non-healthcare professionals. The study also aimed to examine the relationship between anxiety levels and obsessive-compulsive (OC) symptom levels, gender, age, educational level, and personal and family history of chronic diseases. The 664 participants included 395 (59.5%) men and 269 (40.5%) women and comprised 180 (27.1%) healthcare professionals and 484 (72.9%) non-healthcare professionals. The survey included three data collection tools: (i) Sociodemographic data form, (ii) Beck Anxiety Inventory (BAI), and (iii) the Dimensional Obsessive-Compulsive Scale Abriged (DOCS-A) pre- and post-pandemic forms. The BAI scores established a moderate positive correlation with post-pandemic DOCS-A total scores and a weak positive correlation with pre-pandemic DOCS-A total scores (p < 0.001 for both). Pre- and post-pandemic DOCS-A total and subdimension scores were significantly higher in women than in men (p < 0.05). Participants with a personal history of chronic diseases had higher BAI and DOCS-A scores compared to participants with no such history (p < 0.001 and p < 0.001, respectively). The results indicated a significant increase in OC symptoms during the pandemic period compared to the pre-pandemic period and a moderate correlation between the anxiety levels and OC symptom severity. It was also revealed that female gender and personal or family history of chronic diseases posed a higher risk for the increase in anxiety and OC symptoms and healthcare professionals had a higher risk of developing anxiety symptoms compared to non-healthcare professionals.     

Attitudes of Lay People to Withdrawal of Treatment in Brain Damaged Patients

Background

Whether patients in the vegetative state (VS), minimally conscious state (MCS) or the clinically related locked-in syndrome (LIS) should be kept alive is a matter of intense controversy. This study aimed to examine the moral attitudes of lay people to these questions, and the values and other factors that underlie these attitudes.

Method

One hundred ninety-nine US residents completed a survey using the online platform Mechanical Turk, comprising demographic questions, agreement with treatment withdrawal from each of the conditions, agreement with a series of ethical principles and three personality tests.

Results

More supported treatment withdrawal from VS (40.2 % agreed, 17.6 % disagreed) than MCS (20.6 %, 41.2 %) or LIS (25.3 %, 35.8 %). Agreement with treatment withdrawal was negatively correlated with religiosity (r?=??0.272, P?<?0.001), though showed no significant relationship with need for cognition or empathy, and only a partial association with utilitarian judgment in a standard moral dilemma. Support for treatment withdrawal was most strongly associated with endorsement of the importance of patient autonomy, dignity, suffering, best interests. Distributive justice was not given significant weight by most. Importantly, agreement with treatment withdrawal was noticeably higher when considered from a first as opposed to third person perspective for VS (Z?=??6.056, P?<?0.001), MCS (Z?=??6.746, P?<?0.001) and LIS (Z?=??6.681, P?<?0.001).

Conclusion

Lay attitudes to withdrawal of treatment in brain damaged patients are largely shaped by values similar to those central to the secular ethical debate. Neither traditional values such as the sanctity of life nor utilitarian values relating to resource allocation seem to play a central role. Far greater weight is given to autonomy, which may explain why participants were far more willing to endorse withdrawal of treatment when the issue was presented in the first person, or in relation to a concrete case involving a patient’s explicit wishes. Surveys focusing on abstract cases presented in the third person may not provide an accurate picture of lay attitudes to these critical ethical questions.     

Quantitative assessment of visual behavior in disorders of consciousness

The study of eye behavior is of paramount importance in the differential diagnosis of disorders of consciousness (DoC). In spite of this, assessment of eye movement patterns in patients with vegetative state (VS) or minimally conscious state (MCS) only relies on clinical evaluation. In this study we aimed to provide a quantitative assessment of visual tracking behavior in response to moving stimuli in DoC patients. Nine VS patients and nine MCS patients were recruited in a Neurorehabilitation Unit for patients with chronic DoC; 11 matched healthy subjects were tested as the control group. All participants underwent a quantitative evaluation of eye-tracking pattern by means of a computerized infrared eye-tracker system; stimuli were represented by a red circle or a small color picture slowly moving on a PC monitor. The proportion of on- or off-target fixations differed significantly between MCS and VS. Most importantly, the distribution of fixations on or off the target in all VS patients was at or below the chance level, whereas in the MCS group seven out of nine patients showed a proportion of on-target fixations significantly higher than the chance level. Fixation length did not differ among the three groups significantly. The present quantitative assessment of visual behaviour in a tracking task demonstrated that MCS and VS patients differ in the proportion of on-target fixations. These results could have important clinical implications since the quantitative analysis of visual behavior might provide additional elements in the differential diagnosis of DoC.     

Psychological distress and prejudice following terror attacks in France

Terrorist attacks have the capacity to threaten our beliefs about the world, cause distress across populations and promote discrimination towards particular groups. We examined the impact of two different types of attacks in the same city and same year on psychological distress and probable posttraumatic stress symptoms, and the moderating effects of religion or media use on distress/posttraumatic symptoms and inter-group relations. Two panel surveys four weeks after the January 2015 Charlie Hebdo attack (N = 1981) and the November 2015 Bataclan concert hall/restaurant attacks (N = 1878), measured intrinsic religiosity, social and traditional media use, psychological distress (K6), probable posttraumatic stress symptoms (proposed ICD-11), symbolic racism and willingness to interact with Muslims by non-Muslims. Prevalence of serious mental illness (K6 score > 18) was higher after November 2015 attacks (7.0% after the first attack, 10.2% the second, χ2 (1) = 5.67, p < 0.02), as were probable posttraumatic stress symptoms (11.9% vs. 14.1%; χ2 (1) = 4.15, p < 0.04). In structural equation analyses, sex, age, geographic proximity, media use and religiosity were associated with distress, as was the interaction between event and religiosity. Distress was then associated with racism symbolism and willingness to interact with Muslims. Implications are considered for managing psychological trauma across populations, and protecting inter-group harmony.